Journal of midwifery & women's health最新文献

Clinical management of emergency pregnancy care, such as ectopic pregnancy or heavy bleeding with pregnancy of unknown location, includes upholding legal and ethical standards. For health care providers unwilling to provide evidence-based life-saving abortion care due to personal beliefs, clear guidance dictates disclosure of these limitations to the patient and colleagues, followed by immediate referral for appropriate care. However, this decision-making pathway may not be engaged due to a variety of factors: providers’ beliefs preclude adherence to referral responsibilities, political discourse confuses patients as to their options and rights, and a constantly changing state and national legal landscape leads providers to question their ability to practice to their full scope of clinical care. Although this disruption of evidence-based standard of care existed pre-Dobbs, the moral disorder is now heightened. This Clinical Rounds highlights a patient vignette describing the risks of abortion restrictions for patients and providers alike, particularly when an individual provider's concerns for violating institutional guidelines sets a precedent for nursing response and forecloses on collaborative input or ethics consultation. The history of physician-only abortion exceptionalism and exclusion of nurses and midwives despite a significant history of nurses and midwives in abortion care grounds an argument for focusing on the impact of unethical and substandard care on the interprofessional care team leading to moral distress and negative patient outcomes. Patient-centered models of care, such as frameworks common in nursing and midwifery, offer opportunities to consider how all providers practicing to their full scope in interprofessional and collaborative ways, such as in emergency rooms and labor departments, might mitigate obstructions to abortion care that risk pregnant people's lives.

Weight bias toward patients in larger bodies is pervasive among health care providers and can negatively influence provider-patient communication, as well as patients’ behavior and health outcomes. Weight bias has historical roots that perpetuate thinness and Whiteness as the cultural norm. Although weight bias remains socially acceptable in US culture, contributing factors to an individual's body size are complex and multifactorial. Providers and health care systems also consistently use body mass index (BMI) as an indicator of health status, despite its limitations and harmful effects in the clinical setting. This state of the science review presents 8 evidence-based strategies that demonstrate how to mitigate harm from weight bias and improve quality of care and health outcomes for patients living in larger bodies. Person-centered approaches to care include (1) eliminating clinical recommendations to lose weight; (2) shifting from a focus on weight to health; (3) implementing a size and weight-inclusive approach; (4) engaging in weight bias self-evaluation; (5) creating a welcoming environment for patients of all sizes; (6) seeking permission and learning the patient's story; (7) using weight-inclusive language; and (8) re-evaluating clinical guidelines and policies based on BMI. Midwives and other health care providers may benefit from training that re-imagines the delivery of health care to patients in larger bodies.

Over the past 10 years, there has been a rapid expansion of legal and legislative changes in abortion care provision for advanced practice clinicians (APCs), including nurse practitioners, midwives, and physician associates (formerly physician assistants), with most of that expansion occurring in the last several years. This expansion has occurred via several routes (eg, legislative, popular vote, court decision, attorney general opinion), and the patchwork of legal statuses nationally creates confusion for clinicians who are unclear on current regulations. This review explores the historical context of abortion practice for APCs, as well as the primary philosophical and legal concepts relevant to this role development. Since 2012, the number of states permitting abortion practice by APCs has more than quintupled, and the changes to abortion law in the United States in the wake of the 2022 Supreme Court decision in the case of Dobbs v. Jackson Women's Center creates a new imperative to understand the role of APCs in accessing abortion care. Additionally, although the research on abortion safety for APC abortion providers is well-established, the physician-centered paradigm of abortion care has limited the ability of APCs to develop expertise in this essential public and clinical health service.

Cervical laceration (CL), although infrequent, is an often-unrecognized complication of vaginal birth and can cause significant blood loss in the immediate postpartum period. The rate of clinically significant CL ranges from 0.14% to 0.2% of births. Nulliparity, operative vaginal birth, occiput posterior position of the fetus, induction of labor, and episiotomy have been cited as possible risk factors. Much of the available literature regarding CL, however, is dated or anecdotal, and there are varying and inconsistent risk associations with its occurrence. Given this unpredictability, CL should be considered in all women with immediate postpartum hemorrhage when there is difficulty obtaining hemostasis. Although midwives receive training about CLs, the low incidence may lead to delay in diagnosis and management. This Clinical Rounds case presents a composite case of postpartum hemorrhage caused by a CL. Risk factors, diagnosis and midwifery management are discussed.

A recent research report from the Centers for Disease Control and Prevention (CDC) caught my attention and spurred further reading and reflection.¹ This report should push all of us to action to assure that all recipients of perinatal care feel well cared for and able to discuss any topic with their care providers.

The authors of this CDC study described overall maternity care experiences using survey data from more than 2000 mothers who are part of an opt-in community panel. The study revealed that 1 in 5 women (20%) reported mistreatment during childbirth in the United States.¹ That rate was close to 30% for Black, Hispanic, and multiracial respondents. In addition, nearly 30% of respondents reported discrimination of some type, including age, weight, and income. Furthermore, nearly half of respondents reported not asking a question or addressing a concern with their provider.¹

The CDC report is only the latest study to address this problem. Other recent research, including research led by midwives, reports the existence of mistreatment in perinatal care in the United States and offers additional information by birth location and provider type. A survey of more than 2000 women, using patient-designed items, revealed that 1 in 6 (17%) identified some type of mistreatment. Only 5% of those who gave birth in community settings (home or freestanding birth center) identified mistreatment compared with 28% who gave birth in hospitals. As in the CDC study, mistreatment was reported more often by women of color. Mistreatment was less common when midwives were the main prenatal care provider.² A secondary analysis of the same study focused on place of birth and intrapartum provider type among participants who gave birth in their planned location. For this subset of 1290 respondents, mistreatment was less likely for those giving birth in community settings with midwives compared with physicians in hospital settings. Although autonomy was greater for respondents cared for by midwives in hospitals, reported mistreatment was not different compared with those cared for by physicians in hospitals.³

Authors of a qualitative analysis of nearly 100 birth stories from 61 participants, analyzed using previously determined domains of mistreatment, found descriptions of mistreatment in 42.7% of narratives. Most instances were classified as poor rapport, such as poor communication, loss of autonomy, and lack of supportive care; none were physical or sexual abuse.⁴ In an effort to identify health care clinician behaviors that exemplify respectful maternity care, researchers examined the literature within a combined set of rights for respectful care during labor and birth. Specific examples of identified clinician respectful behaviors included providing only clinically indicated and evidence-based care, avo